Anna increasingly gave up going out. She did her shopping online, visits to friends began to tire her, and the thought of leaving home alone caused panic. The worst was on a crowded streetcar – she felt like she would run out of air. Eventually she began to avoid short walks as well. It was hard for her to understand where this fear came from – after all, once upon a time, everyday errands were not so difficult.
If you or someone close to you also happens to avoid certain places or situations because of anxiety – you are not alone with this. Maybe it’s worth taking a closer look?
What exactly is agoraphobia?
Agoraphobia is often confused with fear of open space. Meanwhile, it is not the space itself that causes anxiety, but situations where it is difficult to quickly leave the place or get help. It can be a crowded bus, but also a lonely walk in the park – seemingly opposite, yet equally difficult for a person experiencing agoraphobia.
From the Greek agora means market, phobos means anxiety. Nowadays, a “market” can take many forms: a shopping mall, a subway, a queue in a store, a bridge, a train, or even a video conference. What they have in common is a subjective sense of danger – the fear that something difficult will happen and we won’t be able to cope or get help.
Agoraphobia, classified in both ICD-10 and DSM-5, includes:
- Fear of using public transportation (buses, subways, trains).
- Avoidance of crowded places (shopping malls, concerts, stadiums).
- Fear of being away from home alone.
- Fear of situations where quick escape would be difficult (queues, elevators).
Typical anxiety-provoking situations in agoraphobia:
- traveling on public transportation (buses, subways, trains),
- being in crowds (concerts, shopping malls),
- leaving home alone,
- queues and enclosed spaces (elevators, tunnels),
- open spaces that are difficult to leave quickly (parks, squares).
Agoraphobia can develop slowly – it starts with avoiding one difficult situation, and over time the list of “dangerous places” grows longer. As a result, a person may gradually give up daily activities: shopping, meetings, work, travel.
Relationship to panic attacks
Often agoraphobia accompanies panic disorder. Many people remember the exact location of the first severe anxiety attack – and begin to avoid it. If the attack occurred in a streetcar, for example, the next time, just entering the streetcar can cause severe anxiety. The avoidance mechanism works like a vicious circle: the less often we confront an anxiety, the stronger it becomes. This combination can be particularly acute, as the memory of a panic attack in a particular situation often leads to the development of fear of similar circumstances in the future.
Agoraphobia: Symptoms of agoraphobia
Agoraphobia manifests itself on both mental and physical levels. Recognizing the symptoms is the first step to getting help. Agoraphobia doesn’t always look spectacular – it can manifest itself in subtle daily evasions that, over time, narrow a person’s life to “safe” spaces.
Typical symptoms:
- panic attacks (dizziness, palpitations, shortness of breath),
- severe fear of leaving the house,
- avoidance of crowds and public transportation,
- avoidance of public transportation is a common symptom that significantly affects daily functioning,
- muscle tension, sleep problems,
- feelings of loneliness and social exclusion,
- agoraphobia often co-occurs with other mental disorders, further complicating treatment.
Mental symptoms:
- Intrusive thoughts of loss of control, heart attack or death.
- Psychomotor agitation (visible restlessness, shaking hands).
- Anticipatory anxiety – fear of just leaving the house, occurring long before the planned activity.
Somatic (physical) symptoms:
- Heart palpitations and shortness of breath (present in about 78% of cases)
- Dizziness and a sense of unreality or separation from one’s own body
- Excessive sweating and dry mouth
- Abdominal pain and nausea
Important! Somatic symptoms of agoraphobia are often mistaken for cardiac diseases or other physical ailments. That is why proper differential diagnosis by a specialist is so important.
People suffering from agoraphobia may also experience panic attacks, which are intense episodes of anxiety.
Where does agoraphobia come from?
Agoraphobia, like most mental disorders, does not have a single, simple cause. Rather, it is the result of a complex interaction between biological, psychological and environmental factors. There is no single, universal cause of agoraphobia. Most often it is a combination of several factors:
1. Biological predisposition
Research indicates that anxiety disorders have a hereditary component. Genetic predisposition may increase the risk of developing anxiety disorders, including agoraphobia. Individuals with a family history of anxiety may be more susceptible.
2. Trauma or stress
Loss of a loved one, an accident, prolonged overload – any of these experiences can “trigger” an anxiety mechanism. Traumatic events, such as the death of a loved one, can contribute to the development of agoraphobia.
3. Mindset
People with agoraphobia often overestimate the likelihood of danger and overestimate its consequences. People with agoraphobia may feel anxiety at the very thought of leaving the house. The feeling of anxiety is driven by thoughts like: “What if I pass out and no one can help me?”
4. The vicious cycle of avoidance
The more we avoid difficult situations, the more our mind “learns” that they are dangerous. It’s a vicious cycle that exacerbates anxiety. Avoiding going out leads to increased anxiety and makes daily functioning more difficult.
Diagnosis of agoraphobia
The diagnosis of agoraphobia is made by a doctor after a detailed history. According to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), several criteria are required to diagnose agoraphobia:
- The presence of anxiety in at least two situations on the list (public transportation, open spaces, etc.).
- Avoidance of these situations for at least 6 months.
- Confirmation that the symptoms are not related to other disorders (such as PTSD).
In the diagnosis process, specialists often use the following tools:
- Panic and Agoraphobia Scale (PAS) questionnaire.
- A detailed clinical history taking into account both psychiatric and somatic symptoms.
Treatment of agoraphobia includes psychoeducation, psychotherapy, and ancillary pharmacological treatment. Fear of space and crowds is most often treated with cognitive-behavioral therapy. Antidepressant and anti-anxiety medications may be recommended by a doctor. It is worthwhile to acquire various breathing and relaxation techniques that can be helpful in calming anxiety. Agoraphobia symptoms and treatment are closely related to the development of anxiety disorders.
Relationship to social phobia
Agoraphobia symptoms and open space
Individuals possessed by fear of space manifest a range of somatic symptoms involving multiple systems. Symptoms can include racing heart rate and palpitations, discomfort and tightness in the chest, trembling, excessive sweating, breathing problems and dry mouth. These are accompanied by feelings such as anxiety, uncertainty, loss of control, feelings of being dazed and turned off, depersonalization and derealization, and even fear of death. Panic attacks are very common with agoraphobia. Symptoms can appear in situations and places that have not previously triggered any reaction. Agoraphobia is a disorder that can cause significant difficulties in daily functioning, so it is important for agoraphobia sufferers to seek help from specialists.
When to seek help?
If the fear of leaving home, traveling or being in crowds begins to limit your life, it is worth seeking the support of a psychotherapist. People suffering from agoraphobia should consult a specialist as soon as possible.
Treatment of agoraphobia – the most effective methods
The good news is that agoraphobia is a disorder that undergoes treatment.
Cognitive-behavioral therapy (CBT)
This is currently the best researched form of treatment for agoraphobia. It combines work on beliefs with what is known as exposure – that is, gradual familiarization with fearful situations, in a safe environment and with the support of a therapist.
A meta-analysis by Hofmann and colleagues (2012) found that CBT’s effectiveness in treating anxiety disorders (including agoraphobia) ranges from 60% to 80%. Improvements include a reduction in avoidance of difficult situations, a reduction in the severity of anxiety and an improvement in daily functioning.
CBT cognitive-behavioral therapy may include:
- psychoeducation (what anxiety is, how the body works in a threatening situation),
- work on automatic thoughts and beliefs (“I can’t cope” → “It’s difficult, but I have the tools to cope”),
- relaxation and emotion regulation training,
- gradual exposure to fearful situations (using the so-called hierarchy of fearful stimuli).
Gradual exposure
Gradual exposure is one of the most effective therapeutic techniques used to treat agoraphobia. It involves systematic, controlled and gradual exposure to anxiety-provoking situations, which leads to habituation, i.e. the body’s habituation to the fearful stimuli. We distinguish between imaginal exposure and in vivo, or in reality. Basic principles of gradual exposure
- Hierarchy of anxiety – the first step is to create an individual list of anxiety situations, ranked from least to most frightening. Each situation is assigned an anxiety rating (usually on a scale of 0-10 or 0-100).
- Small steps – therapy begins with exposure to the least anxiety-provoking situations, and only after these are mastered does one move on to more difficult challenges.
- Regularity – regularity of exercise is key. Optimal results are achieved by performing exposures several times a week.
- Persistence in the situation – it is important to stay in the anxiety-provoking situation until the tension level drops significantly (usually by half), rather than running away at the first sign of discomfort.
Working with automatic thoughts
One of the pillars of CBT therapy is learning to recognize and modify thoughts that trigger anxiety or keep it high. Recognizing thoughts that can lead to a panic attack is key in therapy.
Questions can be helpful:
- Do I have evidence that I’m not coping?
- Is what I’m thinking a fact or just a prediction?
- How would someone close to me look at it?
- Does this thought help me calm down and act?
To get a better idea of your thinking patterns, it’s a good idea to keep a thought journal. This simple tool helps you capture the moment when anxiety occurs, and step by step analyze what is happening then – in your head and in your body.
How to use the diary?
Below you will find simple instructions in 6 steps:
- Situation: Describe what happened. Example: “I was supposed to go to the store alone, but already at the door I felt tension.”
- Automatic thought: Make a note of the first thought that came up. “I’m going to faint and no one will help me.”
- Emotion: Write down what you felt and rate it on a scale of 0-100%. Anxiety – 80%, helplessness – 60%
- Evidence for and against: For: “I once almost fainted in line.” Against: “It was when I had a cold. Lately I’ve been able to take a leisurely walk.”
- New, more helpful thought: “I may feel uncomfortable, but it will pass. If it’s necessary, I’ll ask for help.”
- New emotion: rate how you feel after this analysis. Anxiety – 50%, sense of control – 40%
Keeping a diary like this on a regular basis can become a valuable support in your daily work with anxiety, helping you regain normal functioning – especially when you learn to notice that not every thought is telling you the truth.
Breathing techniques and mindfulness
Breathing exercises and mindfulness (mindfulness) practices help lower tension and return to the “here and now,” rather than succumbing to anxiety scenarios. Simple breathing training, such as the 4-7-8 rhythm, can help regulate emotions. Relaxation techniques, such as breath control, can help manage anxiety. Brief mindfulness exercises (e.g., focusing on smells, sounds, body sensations) help to “ground” oneself in difficult moments.
Social support
Understanding and patience from loved ones are extremely important. Sometimes all it takes is for someone to go with us to the store or for a short walk. Small gestures provide a sense of security and help break the isolation. People suffering from agoraphobia need the support of loved ones to successfully cope with their anxiety.
Pharmacotherapy
In many cases, therapists recommend antidepressants such as selective serotonin reuptake inhibitors (SSRIs). These drugs help stabilize mood and reduce the intensity of anxiety reactions. Antidepressants are often used to treat agoraphobia. They can be especially effective when combined with psychotherapy.
Pharmacotherapy should be conducted under the close supervision of a psychiatrist, taking into account the individual needs of the patient. Patients should strictly follow the doctor’s instructions during pharmacological treatment. In the case of agoraphobia, medication can help break the initial wave of anxiety, so that therapeutic work can be undertaken.
Frequently asked questions
How to distinguish agoraphobia from anxiety neurosis?
The main difference is that agoraphobia focuses on specific spatial situations, while anxiety neurosis (anxiety neurosis) is more generalized in nature. With anxiety neurosis, the patient may feel anxious most of the time, with no clear connection to specific situations or places.
Can somatic symptoms be dangerous?
By themselves, the somatic symptoms of agoraphobia do not pose an immediate threat to life, but due to their similarity to symptoms of cardiac or gastrointestinal diseases, it is advisable to consult a doctor to rule out health problems. In addition, prolonged anxiety-related stress can negatively affect overall health.
Will agoraphobia go away on its own? Not likely. Avoidance may temporarily reduce anxiety, but in the long term it intensifies it. Therapy helps break this vicious cycle.
Do I have to leave the house to work on my anxiety? At first – not necessarily. It is important to work on patterns and emotions. Exposures are introduced gradually, in safe conditions.
Is it possible to live with it normally? Yes – many people regain independence and enjoyment of daily life after therapy. Agoraphobia can be effectively treated with therapy and pharmacotherapy.
Summary
Agoraphobia can effectively impede daily life, but it is not a sentence. With the right support – psychotherapy, anxiety management techniques and proximity to another person – it is possible to regain independence and a sense of control.
If you feel that anxiety is taking control of you – you don’t have to go through it alone. It’s worth reaching out for help.
Recommended sources and literature:
- “Anxiety Therapy” – Edmund Bourne
- “Understanding anxiety” – Ronald M. Rapee
- “Overcoming anxiety” – David A. Clark
Source: Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36(5), 427-440.
Link: SpringerLink – full article